Pre-Participation Physical Evaluation
Kansas State High School Activities Association • 601 SW Commerce Place • PO Box 495 • Topeka, KS 66601 • 785-273-5329
PPE
HISTORY FORM (should be filled out by the student and parent/guardian prior to the physical examination) Name Grade School
Sex
Age
Date of birth
Sport(s)
Home Address Personal physician
Phone -
Parent Email
PPE is required annually and shall not be taken earlier than May 1 preceding the school year for which it is applicable. Medicines and Allergies: Please list all of the prescription and over-the-counter medicines, inhalers, and supplements (herbal and nutritional) that you are currently taking: _______________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ No Medications Do you have any allergies? Yes No If yes, please identify specific allergy below. Medicines _________________________ Pollens _________________________ Food ________________________ Stinging Insects ______________________________ What was the reaction? _________________________________________________________________________________________________________________________________ Explain “Yes” answers below. Circle questions you don’t know the answers to.
General Questions
Yes No
Medical Questions
1. Have you had a medical condition or injury since your last check up or sports physical?
27. Do you cough, wheeze, or have difficulty breathing during or after exercise?
2. Has a doctor ever denied or restricted your participation in sports for any reason?
28. Have you ever used an inhaler or taken asthma medicine?
3. Do you have any ongoing medical conditions? If so, please identify below:
30. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?
Asthma
Anemia
Diabetes
29. Is there anyone in your family who has asthma?
Infections
31. Do you have groin pain or a painful bulge or hernia in the groin area?
Other: __________________________________
32. Have you had infectious mononucleosis (mono) within the last month?
4. Have you ever spent the night in the hospital?
33. Do you have any rashes, pressure sores, or other skin problems?
5. Have you ever had surgery?
Heart Health Questions About You
Yes No
7. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
36. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?
8. Does your heart ever race or skip beats (irregular beats) during exercise?
37. Do you have a history of seizure disorder?
9. Has a doctor ever told you that you have any heart problems? If so, check all that apply: High blood pressure A heart murmur High cholesterol A heart infection Kawasaki disease Other: _________
38. Do you have headaches with exercise? 39. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling (Stinger/Burner/Pinched Nerve)? 40. Have you ever been unable to move your arms or legs after being hit or falling?
10. Has a doctor ever ordered a test for your heart? (For example, ECG/ EKG, echocardiogram)
41. Have you ever become ill while exercising in the heat?
11. Do you get lightheaded or feel more short of breath than expected during exercise?
42. Do you get frequent muscle cramps when exercising? 43. Do you or someone in your family have sickle cell trait or disease?
12. Have you ever had an unexplained seizure?
44. Have you had any problems with your eyes or vision?
13. Do you get more tired or short of breath more quickly than your friends during exercise?
45. Have you had any eye injuries?
Yes No
48. Do you worry about your weight? 49. Are you trying to or has anyone recommended that you gain or lose weight?
15. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?
50. Are you on a special diet or do you avoid certain types of foods? 51. Have you ever had an eating disorder?
16. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?
52. Do you have any concerns that you would like to discuss with a doctor?
Females Only
17. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?
Bone And Joint Questions
19. Have you ever had any broken or fractured bones or dislocated joints? 20. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?
46. Do you wear glasses or contact lenses? 47. Do you wear protective eyewear, such as goggles or a face shield?
14. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident, or sudden infant death syndrome)?
18. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game?
34. Have you had a herpes or MRSA skin infection? 35. Have you ever had a head injury or concussion? If yes, how many? _______________________ What is the longest you've been held out of sports or school? __________________ When were you last released?___________________________________________
6. Have you ever passed out or nearly passed out DURING or AFTER exercise?
Heart Health Questions About Your Family
Yes No
Yes No
53. Have you ever had a menstrual period?
Yes No
54. If yes, are you experiencing any problems or changes with athletic participation (i.e., irregularity, pain, etc.)? 55. How old were you when you had your first menstrual period? 56. How many periods have you had in the last 12 months? Explain “yes” answers here
21. Have you ever had a stress fracture? 22. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down syndrome or dwarfism) 23. Do you regularly use a brace, orthotics, or other assistive device? 24. Do you have a bone, muscle, or joint injury that bothers you? 25. Do any of your joints become painful, swollen, feel warm, or look red? 26. Do you have any history of juvenile arthritis or connective tissue disease?
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Signature of athlete _____________________________________________ Signature of parent/guardian ____________________________________________ Date ____________ © 2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.
Rev. 1/15
PPE
Pre-Participation Physical Evaluation
Kansas State High School Activities Association • 601 SW Commerce Place • PO Box 495 • Topeka, KS 66601 • 785-273-5329
PHYSICAL EXAMINATION FORM Name__:
_Date of birth__:_
Date of recent immunizations: Td
Tdap
Hep B
Varicella
HPV
Meningococcal
PHYSICIAN REMINDERS 1. Consider additional questions on more sensitive issues • Do you feel stressed out or under a lot of pressure? • Do you ever feel sad, hopeless, depressed, or anxious? • Do you feel safe at your home or residence? • Have you ever tried cigarettes, chewing tobacco, snuff, or dip? • During the past 30 days, did you use chewing tobacco, snuff, or dip?
• Do you drink alcohol or use any other drugs? • Have you ever taken anabolic steroids or used any other performance supplement? • Have you ever taken any supplements to help you gain or lose weight or improve your performance? • Do you wear a seat belt and use a helmet?
2. Consider reviewing questions on cardiovascular symptoms (questions 5–14).
EXAMINATION Height
Weight
Vision R 20/
L 20/
Male
Female
Corrected: Yes
|
BP (reference gender/height/age chart)****
/
(
/
) Pulse
No
MEDICAL NORMAL ABNORMAL FINDINGS Appearance • Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency) Eyes/ears/nose/throat • Pupils equal • Gross Hearing Lymph nodes Heart * • Murmurs (auscultation standing, supine, +/- Valsalva) • Location of point of maximal impulse (PMI) Pulses • Simultaneous femoral and radial pulses Lungs Abdomen Genitourinary (males only)** Skin • HSV, lesions suggestive of MRSA, tinea corporis Neurologic*** MUSCULOSKELETAL Neck Back Shoulder/arm Elbow/forearm Wrist/hand/fingers Hip/thigh Knee Leg/ankle Foot/toes Functional • Duck-walk, single leg hop *Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam. **Consider GU exam if in private setting. Having third party present is recommended. ***Consider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion. ****Chart found in: The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Pediatric BP mobile application can also be used.
Cleared for all sports without restriction Cleared for all sports without restriction with recommendations for further evaluation or treatment for _______________________________________________________ _______________________________________________________________________________________________________________________________________ Not cleared Pending further evaluation For any sports For certain sports __________________________________________________________________________________________________________________ *Reason _________________________________________________________________________________________________________________________ Recommendations ___________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ I have examined the above-named student and student history and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/ guardians). Name of healthcare provider (print/type)______________________________________________________________________________________ Date ________________ Address ___________________________________________________________________________________________________ Phone _________________________ Signature of healthcare provider___________________________________________________________________________________________, MD, DO, DC, PA-C, APRN (please circle one) ©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.
Rev. 1/15
ATTENTION PARENTS AND STUDENTS KSHSAA ELIGIBILITY CHECK LIST PPE shall not be taken earlier than May 1 preceding the school year for which it is applicable.
NOTE: Transfer Rule 18 states in part, a student is eligible transfer-wise if: BEGINNING SEVENTH GRADER—A seventh grader, at the beginning of his or her seventh grade year, is eligible under the Transfer Rule at any school he or she may choose to attend. In addition, age and academic eligibility requirements must also be met. BEGINNING NINTH GRADERS IN A THREE-YEAR JUNIOR HIGH SCHOOL—So that ninth graders of a three-year junior high are treated equally to ninth graders of a four-year senior high school, a student who has successfully completed the eighth grade of a two-year junior high/middle school, may transfer to the ninth grade of a three-year junior high school at the beginning of the school year and be eligible immediately under the Transfer Rule. Such a ninth grader must then as a tenth grader, attend the feeder senior high school of their school system. Should they attend a different school as a tenth grader, they would be ineligible for eighteen weeks. ENTERING HIGH SCHOOL FOR THE FIRST TIME—A senior high school student is eligible under the Transfer Rule at any senior high school he or she may choose to attend when senior high is entered for the first time at the beginning of the school year. In addition, age and academic eligibility requirements must also be met.
For Middle/Junior High and Senior High School Students to Retain Eligibility Schools may have stricter rules than those pertaining to the questions above or listed below. Contact the principal or coach on any matter of eligibility. A student to be eligible to participate in interscholastic activities must be certified by the school principal as meeting all eligibility standards. All KSHSAA rules and regulations are published in the official KSHSAA Handbook which is distributed annually and is available at your school principal’s office. Below Are Brief Summaries Of Selected Rules. Please See Your Principal For Complete Information. Rule 7 Physical Evaluation - Parental Consent—Students shall have passed the attached evaluation and have the written consent of their parents or legal guardian. Rule 14 Bona Fide Student—Eligible students shall be a bona fide undergraduate member of his/her school in good standing. Rule 15 Enrollment/Attendance—Students must be regularly enrolled and in attendance not later than Monday of the fourth week of the semester in which they participate. Rule 16 Semester Requirements—A student shall not have more than two semesters of possible eligibility in grade seven and two semesters in grade eight. A student shall not have more than eight semesters of possible eligibility in grades nine through twelve, regardless of whether the ninth grade is included in junior high or in a senior high school. NOTE: If a student does not participate or is ineligible due to transfer, scholarship, etc., the semester(s) during that period shall be counted toward the total number of semesters possible. Rule 17 Age Requirements—Students are eligible if they are not 19 years of age (16, 15 or 14 for junior high or middle school student) on or before September 1 of the school year in which they compete. Rule 19 Undue Influence—The use of undue influence by any person to secure or retain a student shall cause ineligibility. If tuition is charged or reduced, it shall meet the requirements of the KSHSAA. Rules 20/21 Amateur and Awards Rules—Students are eligible if they have not competed under a false name or for money or merchandise of intrinsic value, and have observed all other provisions of the Amateur and Awards Rules. Rule 22 Outside Competition—Students may not engage in outside competition in the same sport during a season in which they are representing their school. NOTE: Consult the coach or principal before participating individually or on a team in any game, training session, contest, or tryout conducted by an outside organization. Rule 25 Anti-Fraternity—Students are eligible if they are not members of any fraternity or other organization prohibited by law or by the rules of the KSHSAA. Rule 26 Anti-Tryout and Private Instruction—Students are eligible if they have not participated in training sessions or tryouts held by colleges or other outside agencies or organizations in the same sport while a member of a school athletic team. Rule 30 Seasons of Sport—Students are not eligible for more than four seasons in one sport in a four-year high school, three seasons in a three-year high school or two seasons in a two-year high school. Rev. 1/15
Student’s Name _______________________________________________ (PLEASE PRINT CLEARLY)
To be eligible for participation in interscholastic athletics/spirit groups, a student must have on file with the superintendent or principal, a signed statement by a physician, chiropractor, physician's assistant who has been authorized to perform the examination by a Kansas licensed supervising physician or an advanced practice registered nurse who has been authorized to perform this examination by a Kansas licensed supervising physician, certifying the student has passed an adequate physical examination and is physically fit to participate (See KSHSAA Handbook, Rule 7). A complete history and physical examination must be performed annually before a student participates in KSHSAA interscholastic athletics/cheerleading. The annual history and the physical examination shall not be taken earlier than May 1 preceding the school year for which it is applicable. The KSHSAA recommends completion of this evaluation by athletes/cheerleaders at least one month prior to the first practice to allow time for correction of deficiencies and implementation of conditioning recommendations.
Parent or Guardian Consent
I do not know of any existing physical or any additional health reasons that would preclude participation in activities. I certify that the answers to the questions in the HISTORY part of the Preparticipation Physical Examination (PPE), are true and accurate. I approve participation in activities. I hereby authorize release to the KSHSAA, school nurse, certified athletic trainer, school administrators, coach and medical provider of information contained in this document. Upon written request, I may receive a copy of this document for my own personal health care records. I acknowledge that there are risks of participating, including the possibility of catastrophic injury. I hereby give my consent for the above student to compete in KSHSAA approved activities, and to accompany school representatives on school trips and receive emergency medical treatment when necessary. It is understood that neither the KSHSAA nor the school assumes any responsibility in case of accident. The undersigned agrees to be responsible for the safe return of all equipment issued by the school to the student.
The above named student and I have read the KSHSAA Eligibility Check List and how to retain eligibility information listed in this form.
For Middle/Junior High and Senior High School Students to Determine Eligibility When Enrolling If a negative response is given to any of the following questions, this enrollee should contact his/her administrator in charge of evaluating eligibility. This should be done before the student is allowed to attend his/her first class and prior to the first activity practice. If questions still exist, the school administrator should telephone the KSHSAA for a final determination of eligibility. (Schools shall process a Certificate of Transfer Form T-E on all transfer students.) YES NO 1. 2. 3. 4.
Are you a bona fide student in good standing in school? (If there is a question, your principal will make that determination.) Did you pass at least five new subjects (those not previously passed) last semester? (The KSHSAA has a minimum regulation which requires you to pass at least five subjects of unit weight in your last semester of attendance.) Are you planning to enroll in at least five new subjects (those not previously passed) of unit weight this coming semester? (The KSHSAA has a minimum regulation which requires you to enroll and be in attendance in at least five subjects of unit weight.) Did you attend this school or a feeder school in your district last semester? (If the answer is “no” to this question, please answer Sections a and b.) a. Do you reside with your parents? b. If you reside with your parents, have they made a permanent and bona fide move into your school’s attendance center?
The student/parent authorizes the school to release to the KSHSAA student records and other pertinent documents and information for the purpose of determining student eligibility. The student/parent also authorizes the school and the KSHSAA to publish the name and picture of student as a result of participating in or attending extra-curricular activities, school events and KSHSAA activities or events.
Parent or Guardian’s Signature
Date
Student’s Signature Date Birth Date Grade Rev. 1/15
